Chapter 82. Electroconvulsive Therapy (ECT)

• Used to treat severe depression, mania, and schizophrenia
• Therapeutic effects thought to result from release of neurotransmitters or reestablishment of neurotransmitter levels
• Typically given three times a week for 2 to 4 weeks acutely, then as needed
• Typically started as inpatient, then possibly administered as outpatient if needed
• General anesthesia is preferred for ECT treatments

• Standard ASA NPO guidelines apply
• Have patient void before the procedure
• Contraindications:
  • MI within past 3 months, severe angina
  • CHF, aneurysm of any major vessel
  • Pheochromocytoma
  • Cerebral tumor, elevation of ICP
  • Cerebral aneurysm
  • Recent CVA
  • Respiratory failure
• Precautions:
  • Pregnancy
  • Thyrotoxicosis
  • Cardiac dysrhythmias
  • Glaucoma and retinal detachment
  • Pacemaker, ICD (to be deactivated before the procedure)
• Medications:
  • Tricyclic antidepressants can increase the risk of HTN, rhythm and conduction problems, and confusion
  • SSRIs and reversible MAOIs can increase the risk of prolonged seizure
  • Lithium increases the risk of confusion, and can prolong the action of succinylcholine: maintain lithium level around 0.6 mEq/L
  • Carbamazepine can prolong the action of succinylcholine
  • Chronic benzodiazepine treatment can make it more difficult to induce seizures. Flumazenil 0.2–0.3 mg at induction is usually effective without causing withdrawal or prolonged seizures

Medications needed are an induction agent and a muscle relaxant

• Bite block placed to prevent injury to teeth and tongue during seizure (see Figure 82-1)
• Sequence of events: IV placement, pre-oxygenate, induction agent, muscle relaxant, place bite block, ECT, assist with ventilation if necessary; provide oxygen by mask or nasal cannula throughout
• ECT results in a generalized tonic-clonic seizure and brief parasympathetic discharge (PSD) followed by sympathetic discharge (SD). There is a brief cerebral vasoconstriction followed by vasodilatation, with increase in CBF, ICP, and oxygen consumption
• PSD results in bradycardia, possible asystole (rare), increased secretions, increased gastric and intraocular pressures
• SD results in tachycardia, hypertension, increased myocardial oxygen demand, and possible dysrhythmias
• Therefore, the following medications should be available immediately:
  • Labetalol, esmolol, nicardipine, verapamil, atropine
• If the seizure is too short (<20 seconds):
  • Decrease hypnotic dose or use different medication, hyperventilate before shock
• If the seizure is too long (>90 seconds):
  • Administer more hypnotic (propofol), or midazolam
• Possible complications (besides those listed above):
  • Laryngospasm, apnea
  • Aspiration
  • Tongue biting, mandible dislocation, long bone fracture, myalgias

• Surveillance in PACU. Same discharge criteria as surgical patients
• Side effects include:
  • Amnesia
  • Agitation
  • Confusion
  • Headache
  • Nausea and vomiting
• Rare complications include:
  • Myocardial ischemia and/or infarct
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